Health Promotion International, Vol. 16, No. 1, 73-78,
March 2001
© Oxford University Press 2001
Does reported health promotion activity neglect people with ill-health?
Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland, New Zealand and 1 Department of General Practice and Primary Health Care, University of Auckland, New Zealand
Address for correspondence: Dr S. Buetow, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland, New Zealand
SUMMARY
Considering health as an alternative to ill-health ignores the multidimensionality of both concepts and invites neglect of health promotion as a multidimensional activity in persons with known ill-health. Drawing on the Ottawa Charter and M
ori perspectives of health, we interpret (ill) health according to people's ability to function in their environment by developing physical, psychological, social and spiritual resources for living. We use this framework to test empirically our hypothesis that although the concept of health promotion has always included people with ill-health, the practice of health promotion has continued to neglect them. Our exploratory review of articles published during 1989–99 and indexed on three electronic databases suggests widespread omission of people with ill-health from research on interventions for health promotion. Of 881 citations, approximately three-quarters included people without ill-health in any dimension. This finding could reflect a failure to include these people in health promotion, to describe activity to improve their health as health promotion, or both. Supporting the latter interpretation is uncertainty over the meaning of health, and the targeting of health promotion at groups at high risk of ill-health and ‘all’ persons. We need therefore to enable health promotion activity to include ill people explicitly.
Key words: health; health promotion; intervention; multidimensional
INTRODUCTION
Health, suggests post-modern writer, David Morris, is ‘far too important to be wasted on people who are perfectly well’ (Morris, 1998
). Looking beyond the hyperbole, Morris asserts that for most people perfect wellness is a fantasy. Each of us passes through a life trajectory of health, interpenetrated by ill-health, though the nature and perception of health and ill-health can vary over time and geographically within and between individuals. Indeed, ill-health is part of daily life rather than an infrequent event (Dean and Kickbusch, 1995), and chronic ill-health has grown in relative importance since World War II (Susser and Susser, 1996). That health ‘happens not so much in the absence of illness as in its presence’ (Morris, 1998) is due to the multiple ‘levels’ on which health and ill-health can coexist within or between different ‘dimensions’ of health.
People with ill-health can benefit from opportunities to increase control over, and improve, their health. This need is no smaller than that of other people. Indeed it is possibly greater, since people with ill-health have a clearly defined capacity to benefit from health. Furthermore, in persons who feel vulnerable because of ill-health or anxiety about symptoms, health promotion has increased effectiveness (Sanson-Fisher et al., 1992) and can provide the foundations for identifying and overcoming obstacles to inequalities in health (Seedhouse, 1997).
Although health promotion as a concept has always included people with ill-health [World Health Organization (WHO), 1992], we wish to consider whether the ‘practice’ of health promotion has neglected this group. Our consideration of this question results from our perceptual experiences and from concerns about how health has been defined. We note these concerns before suggesting our own definition of health. In the context of uncertainty over the meaning of health promotion, we use this definition to inform and interpret an exploratory review of the extent to which health promotion interventions, as reported in published research literature, have included people with ill-health.
WHAT IS HEALTH?
The reality of coexisting health and ill-health, and the search for meaning and value in health promotion presume an appropriate definition of health. Although ‘health is (probably) a contested concept’ (Adams and Armstrong, 1996), the WHO constitution of 1948 (WHO, 1948) retains authority in defining health as:
A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.
In this journal, the ‘Health Promotion Glossary’ (Nutbeam, 1998) cites this much-quoted definition in seeking to define ‘health’. The WHO definition has value in recognizing the positive and multidimensional character of health. However, it is also much criticized. Among other things, it conceptualizes health as an ideal state and replaces the ambiguous concept of health with ‘the equally ambiguous notion of well-being’ (Noack, 1991; Seedhouse, 1995).
Our concern here is that the WHO definition is not conducive to health promotion. If health is ‘complete’ well-being, health requires no improvement because, so to speak, the glass is full. Also, the definition implies that anything less than complete well-being is not health, i.e. absurdly, that we all have (total) ill-health rather than the potential for, or reality of, coexisting health and ill-health. Within the context of health promotion, Nutbeam (Nutbeam, 1998) notes that health has therefore been regarded in the Ottawa Charter (WHO, 1986) as:
A resource for everyday life, not the object of living. It is a positive concept, emphasizing social and personal resources as well as physical capabilities.
This interpretation allows for health promotion in people with ill-health. However, in not specifying dimensions of health, it draws implicitly on the 1948 WHO definition of health, and so does not disavow that definition. Below, we suggest why the dimensions stated in the 1948 definition are incomplete. In addition, the Ottawa Charter emphasizes the interconnectedness of health to the external environment but not in considering the meaning of health per se. Continuing uncertainty over the meaning of ‘health’ has contributed, in turn, to different interpretations of health promotion. Therefore, we seek now to refine the Ottawa interpretation of health by suggesting our own version for the following reasons: (i) to address the foregoing concerns; and (ii) so that we can test the hypothesis that health promotion in the published literature has neglected people with known ill-health.
The four-sided house
Our interpretation of health draws on two main perspectives of health (hauora) by Mori, New Zealand's indigenous people. Mori view health first as a ‘four-sided house’ (whare tapa wh), comprising the interconnecting ‘rooms’ of spiritual (taha wairua), physical (taha tinana), family (taha whnau), and emotional or mental health (taha hinengaro) (Durie, 1994; National Health Committee, 1998). Unless ‘all four dimensions are vital and thriving’, a person cannot be healthy (Crengle, 1999). Mori emphasize that:
Although an individual may access a service with a particular health or illness need, this need cannot be seen in isolation from the other dimensions of health. (Crengle, 1999
Despite emphasizing a notion of balance, this holistic concept of health differs from the WHO (WHO, 1948) definition by anchoring health on a spiritual rather than somatic base (Durie, 1994). As Durie states:
Taha wairua is generally felt by M
The foregoing concepts guide the philosophy, development and delivery of primary health care services by Mori for Mori. Secondly, Mori also view health in the context of economic, cultural (including land), education and employment influences. As Crengle has explained (Crengle, 1999):
It is unrealistic to expect people to ... take their children to clinics for routine immunizations when they have more pressing concerns about the standard of their housing, having enough money to feed their children ....
Thus, the model of ‘positive Mori development’ states that Mori health improvements depend on ‘social, economic and cultural advancement within a framework of Mori self-sufficiency and Mori control’. Against this background, we define personal health as:
An individual's ability to function in their environment by developing physical, psychological, social and spiritual resources for living.
These resources can be conceived of as physical, psychological, social (including family) and spiritual health. Our definition acknowledges the cultural significance of health, and not merely its physical, mental and social foundations. It also makes explicit that health is intimately related to the circumstances people live in, which are a product of historical, social, economic, cultural, political and other forces. Our definition permits the same person to have, say, poor physical health but good social health, and health and ill-health at different levels of, say, psychological health if, for example, a person lacks confidence but is happy.
The resulting state of disequilibrium can be reflected in one's ‘health balance’, which in turn can describe the potential for health gain (Noak, 1991). However, it is important not to lose sight of the dimensions composing that balance, and so they provide the four ‘rooms’ in which we test empirically the extent to which people with ill-health have been explicitly included in studies of health promotion.
IMPLICATIONS FOR HEALTH PROMOTION
Beyond the issue of what health means, the concept of health promotion has been defined in different ways. Some ‘focus on principles, others attempt to specify goals, others the kind of activities embraced’ (Delaney, 1994).
The WHO states that health promotion synthesizes the choice and responsibility of people to change their ways and conditions of living in their own environment (WHO, 1984). According to the Ottawa Charter (WHO, 1986), health promotion seeks to enable all people to increase control over the determinants of their health, and thereby to improve their health. Suggesting how this enablement can take place, Tannahill has viewed health promotion as comprising the overlapping activities of health education, prevention and health protection (Tannahill, 1992).
Implicit in these conceptions is the belief that enablement is possible. However, different ethnic groups do not all concur. Among Samoans for example, ‘health is not seen as something which can be promoted ... Samoans do not seek better ways, in the sense of different or alternative methods for preventing disease or ability ... [and] see sickness as an inevitable, unpredictable and powerful discontinuity in the flow of life’ (Kinloch, 1985). WHO definitions do not accommodate this fatalistic perspective of health.
Providers also vary in their interpretations of health promotion. Four focus groups of Melbourne general practitioners (GPs) developed three concepts of health promotion for older people (Kerse et al., 1997). The first abstract view was that health promotion is all medical care and is integrated into all consultations. Other GPs understood health promotion as a comprehensive range of activities that tend to be undertaken opportunistically or thirdly, as specific activities for disease prevention, such as Pap smears and cholesterol measurement. The last perspective, in particular, may reflect an unwillingness to accept the multidimensionality of positive health or barriers to promoting such health, and thereby discourages health promotion among persons with ill-health.
Literature review
To establish the range and frequency of interpretations of ‘health promotion interventions’ in articles published during 1989–1999, N. M. K. searched the titles, key words and abstracts of articles summarized in three electronic databases—CinHahl, Medline and PsychLitt—for the combination of two subject headings: ‘health promotion’ and ‘intervention’. She downloaded complete references into an Endnote database and categorized them into one of five possible groups. Drawing on our definition of health, these groups are people with: (i) no identified ill-health, (ii) physical ill-health, (iii) mental ill-health, (iv) social ill-health and (v) spiritual ill-health. A dominant group was selected where studies fell into more than one group. Table 1 defines in conceptual and operational terms the groups of people with ill-health, and suggests examples for each group.
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We found that spiritual ill-health is difficult to express operationally. Durie has asked whether spirituality is ‘of any practical value if it could not be measured?’, answering ‘The critics felt not’ (Durie, 1984). Kingi and Durie have added that M
ori spirituality ‘means different things to different people ... and considers aspects of wellness that are often nondescript and intangible’ (Kingi and Durie, 2000). Nevertheless, their measure of Mori mental health outcomes incorporates four dimensions of Mori spirituality: (i) dignity and respect; (ii) cultural identity; (iii) personal contentment; and (iv) spirituality in terms of non-physical existence. Poor scores on these dimensions would suggest, therefore, that spiritual ill-health can help to explain an individual's state of mental health or ill-health. The studies N. M. K. identified were categorized from abstracts, where reported. Otherwise, titles were used only if deemed sufficiently informative to permit estimation of the most appropriate group. Articles whose titles did not meet this criterion were excluded, as were articles describing the theoretical base of health behaviours or interventions, factors predicting risk behaviour and editorials. Citations in each group were enumerated. Evaluation of the quality or effectiveness of health promotion interventions was beyond the scope of our review.
Of 1608 citations, 881 (55%) reported use of a health promotion intervention. Of these 881 citations, 682 (77%) included persons without ill-health on any dimension. Studies including persons with physical ill-health numbered 122 (14%). Table 2 enumerates the various forms of physical ill-health identified in the literature. Approximately three-quarters of the citations (93/122) described chronic conditions, and one-fifth (25/122) referred to cardiovascular disease or hyperlipidaemia. The table also breaks down the 55 of 881 studies (6%) of people with psychological ill-health, and shows that almost half involved people with alcohol or other drug problems. Remaining studies comprised persons with social difficulties (22 studies, 2%). No identified studies promoted health in persons with spiritual ill-health. These results include six studies considering ill-health on more than one dimension.
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DISCUSSION
The foregoing estimates provide a guide as to whether articles on health promotion interventions have included people with ill-health. Our use of informative titles or even abstracts alone permits only a crude categorization of articles. However, our aim was not to generate very precise estimates but to indicate the general nature and direction of research from the information available to all persons searching research databases electronically for literature.
As a guide to reported practice, our results invite at least two interpretations. The first is that interventions designed to ‘promote’ the health of people with major physical or psychological diagnoses of ill-health have not necessarily been reported in the literature as ‘health promotion’. These interventions might have been targeted (i) at ill-health itself, whereupon health promotion includes all health care and conflates health and ill-health as starting points for health improvements, or (ii) at a coexisting dimension or level of health, as might occur with, say, steps to improve physical activity in a person with cancer.
The second interpretation is that most published interventions to promote health have focused on people without overt ill-health. This interpretation suggests scope to expand the practice of health promotion to encompass persons with physical, mental, social and spiritual ill-health. There is most likely some truth in both interpretations. Supporting the face validity of the second one is the fact that we predicted it because of the tendency still to view health as either the absence of ill-health (health negatively defined) or the opposite of ill-health. Neither conceptualization recognizes that ill-health does not remove the opportunity to live a fulfilling, productive and healthy life.
Also supporting the second interpretation are strategies for health promotion that target ‘all’ persons, where the collectivity of ‘all’ is undifferentiated. Focusing the health promotion lens on the whole ‘forest’ makes it all too easy to miss certain types of ‘trees’. It is also easy to equate ‘all’ with what Kemm called neutral health (normality) (Kemm, 1993). This acts against health promotion in persons with known ill-health, as does a focus on people at high risk of ill-health since, by definition, the latter group does not (yet) have ill-health.
CONCLUSION
Health and ill-health are not binary opposites. They describe our ability as individuals to function in our own environment by developing physical, psychological, social and spiritual resources for living. These resources, in turn, define different dimensions and levels of health (or ill-health). This conceptualization, which draws on the Ottawa Charter and Mori perspectives of health, can help to explain why, as Morris demonstrates (Morris, 1998), health occurs in the presence of ill-health rather than typically in its absence.
Almost a decade ago, the WHO organized an international symposium to suggest strategies for health promotion in chronically ill people (WHO, 1992). The concept of health promotion in people with ill-health was then in its infancy. Drawing on our own interpretation of health, our literature review suggests little subsequent progress has taken place. Published research has continued to neglect interventions for ‘health promotion’ in people with identified ill-health. To an unknown extent, the literature might not have reported activity to promote health as ‘health promotion’. However, whether it has or not, a priority is still to develop and disseminate concepts of health and health promotion that allow explicitly for health and ill-health. The extension of health promotion activity to include people with ill-health would enable providers and patients to view health care and ill-health more positively than current practice allows.
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